Senate Passes Doc Fix Bill

The U.S. Senate tonight passed a bill entitled the “Physician Payment and Therapy Relief Act” that will postpone a 23% cut in Medicare reimbursement to physicians from December 1^st to January 1^st.   The bill was constructed by Senator Max Baucus (D-MT), chair of the Senate Finance Committee, and Senator Chuck Grassley (R-IA).   Senators Baucus and Grassley also announced that they would seek a second “doc fix” that would further delay the scheduled December 1^st pay cut as well as the 2% pay cut scheduled for January 1, 2011.  The second bill would postpone all pending physician reimbursement cuts until January 1, 2012. 

Unfortunately for physicians facing the 23% pay cut in 12 days, the House has already adjourned for the Thanksgiving holiday, meaning that they cannot take up consideration of the Senate bill before November 29^th.  There is currently a bill proposed by Representative John Dingell (D-MI) that would extend the effective date of Medicare cuts until January 1, 2012.  Whether the House pursues Dingell’s bill or takes up the Senate bill on the 29^th is unclear, but spokespersons for House Speaker Nancy Pelosi (D-CA) have indicated that the House would consider “doc fix” legislation prior to the December 1^st deadline.

ACEP sends letter to Dr. Berwick, CMS

ACEP sent a letter to newly appointed CMS administrator Dr. Donald Berwick this week.  The letter outlines emergency physician concerns with several health care reform law implementation issues and highlights specific provisions of the new law that affect the delivery of emergency care.  The letter is as presented here:

 July 19, 2010

Donald M. Berwick, MD, MPP, FRCP 

Administrator Centers for Medicare & Medicaid Services

200 Independence Avenue, SW 

Washington, DC 20201

Dear Dr. Berwick:

On behalf of the American College of Emergency Physicians (ACEP) and our 28,000 members, I want to congratulate you on your appointment as Administrator of the Centers for Medicare & Medicaid Services (CMS). We look forward to working with you and your staff during this critical time that the new health care reform law regulations are being promulgated and we believe your clinical and health care policy experience give you a unique perspective on how these rules may impact the delivery of health care in America.

As an elected member of the Institute of Medicine (IOM), we're sure you are familiar with the 2006 IOM reports on the "Future of Emergency Care in the United States Health System," which detailed the challenges and concerns this nation faces in maintaining access to emergency medical care. As articulated in the IOM reports, America's emergency medical system as a whole is overburdened, underfunded and highly fragmented. As a result, ambulances are diverted from emergency departments once every minute on average and patients in many areas may wait hours, or even days, for hospital beds causing admitted patients to be boarded in the emergency department and redirecting precious emergency care resources away from incoming patients.

Emergency departments in this country handle more than 120 million patient visits per year and utilization of our services continues to steadily increase. As we have learned from observing the evolution of the Massachusetts medical care system, and its near universal coverage, emergency department utilization has actually increased in that state, rather than decreased, as many projected. We believe this is the result of a number of factors, including the federal mandate applied by the Emergency Medical Treatment and Labor Act (EMTALA), the lack of internal medicine physicians and general practitioners in the state, injuries and illnesses that occur after normal physician office business hours, and the fact that emergency departments continue to be the sole source of access to the health care system for many in that state, despite their insurance status. The one true lesson from Massachusetts is that coverage does not equal access.

Frankly, we are concerned that the combination of health care law reforms and the general delay in producing more primary care physicians could potentially overwhelm America's emergency departments, many of which currently operate at or above capacity on a regular basis. In particular, we would like to focus your attention of the followingprovisions of the "Patient Protection and Affordable Care Act" and the "Health Care and Education Reconciliation Act:"

Patient Protections (§10101) - This measure extends the "prudent layperson standard" to group health plans, or issuers of group or individual health plans, which offer hospital emergency department services, as well as eliminates the need for prior authorization and provides parity in coverage and patient co-payments for in- and out-of-network providers. We urge you to consider expanding these important patient protections to grandfathered health plans as well.

Hospital Value-Based Purchasing Program (§3001) – As this program advances, we want to ensure measures that will improve emergency department efficiencies are considered an essential component of this plan.

Improvements to PQRI System (§3002) – Please assure emergency physician measures continue to be available in the PQRI program and that these measures promote integration of clinical reporting using electronic health records, as well as demonstrate both meaningful use of electronic health records and quality of care furnished to the patient.

Value-Based Payment Modifier (Physician Fee Schedule) (§3007) – As CMS develops its own transparent episode grouper software; it must account for the unique delivery aspects of emergency services. In addition, it is critical that future risk-based measures developed by HHS ensure emergency physician measures are applied only to services that are within the control of the physicians.

Medicare Shared Savings Program (§3022) and Payment Bundling (§3023) – We urge you to recognize the important role emergency physicians play in providing the full continuum of care to Medicare beneficiaries. There must be commensurate recognition of these distinctive services as an integral part of any Accountable Care Organization (ACO) and through the coordination of bundled payments for an episode of care.

Distribution of Additional Residency Positions (§5503) – Due to the statutory obligation to provide at least 75% of the redistributed residency positions to primary care or general surgery, it is even more imperative that CMS provide as many of the remaining slots to emergency medicine residency programs. The expected immediate increase in emergency department visits demands that we accelerate the availability of residency-trained emergency physicians in our communities.

National Health Care Workforce Commission (§5101) – The growing disparity between the increasing number of emergency department visits each year and the decreasing number of emergency departments is alarming and of great concern to us and our constituents. We strongly encourage you to highlight the education and training needs of emergency medicine as the commission proceeds.

Patient-Centered Outcomes Research (§6301) – Due to the integral role of emergency physicians in providing all types of care for elderly patients, we ask that the emergency medicine perspective be represented in the identification of research priorities and the establishment and implementation of the research project agenda.

Extension of Medical Malpractice Coverage (§10608) – The law extends Federal Tort Claims Act liability protections to an officer, governing board member, employee or contactor of a free clinic. This is an important recognition of the unique role of those individuals who provide medical services without requiring compensation from the patient. As you know, the federal mandate of the Emergency Medical Treatment and Labor Act (EMTALA) requires emergency department physicians and many on-call specialists to provide similar, and in fact more comprehensive, services as those provided at free clinics with a substantial burden of uncompensated care. We urge you to review the unique requirements on physicians who provide EMTALA- related services and consider how the Federal Tort Claims Act may be applied to ensure the availability of these emergency and on-call physicians.

In addition, we are writing to request your assistance with another matter of significant importance to the coordination and delivery of high-quality medical care in America's emergency departments. Senator Debbie Stabenow (D-MI) has requested a formal response from HHS on her proposal to create a CMS working group that would be responsible for reviewing issues affecting access to emergency care and for developing standards and measures to reduce emergency department boarding and crowding, as well as ambulance diversion. Both of these issues can have dire consequences for patient care and we urge you to develop your response to her request as soon as possible.

Thank you for your consideration of these important issues. As you know, enactment of health care reform was only the first step. We look forward to working with you to ensure the implementation of these laws help our patients receive the best medical care possible, including maintaining access to lifesaving emergency medical services that are so vital to our communities.

Sincerely,

Angela Gardner, MD, FACEP

President

Senate Back to Work Today

The Senate is back to work today after a two week break.  There is a scheduled cloture vote that would limit debate on a bill implementing a 30-day freeze to a 21% Medicare cut for doctors.  The 21% reimbursement cut for physicians technically took effect April 1, 2010, but CMS has requested that physicians hold billing for two weeks in anticipation of Senate action today.

Republicans and Democrats reached a stalemate on the bill prior to the spring recess, largely based on disagreement about whether the $9.2 billion cost of the bill should be offset.  The success of a cloture vote today would allow lawmakers another 20 days to consider a longer extension or a permanent solution to the scheduled reductions.  In addition, the more than 200,000 people who lost their jobless benefits on April 5, including subsidies to pay for health insurance through COBRA, would have an opportunity to apply for a one month extension of those benefits.    

Democratic leaders have pledged to work to make an extension retroactive to April 1.  The American College of Emergency Physicians is working with lawmakers to develop a permanent fix to the situation that leaves emergency physicians facing large Medicare cuts yearly based on a formula that is flawed.

Physicians Face 21% Payment Cut at Midnight

The fight over the flawed SGR (Sustainable Growth Rate) formula is familiar to physicians. Every year the scheduled cut in fees increases, and every year physicians fight for and eventually obtain a postponement. Friday, the House passed HR 4691, legislation that extends a number of expiring programs for 30 days, including current Medicare physician payment rates, which would once again postpone the 21% cut that was scheduled to take effect this year. The Senate attempted unsuccessfully on several occasions Friday night and Saturday morning to pass the same bill by unanimous consent, but objections were raised by Senator Jim Bunning (R-KY), on the basis that $10 billion cost of the program extensions was not offset . The Senate has adjourned for the weekend, so the 21% Medicare physician payment cut will be effective on Monday, March 1.

The Centers for Medicare and Medicaid Services (CMS) are notifying their contractors to hold Medicare physician claims for 10 business days, effective Monday. The agency will also be sending out a similar message on its various list serves this afternoon to physicians, and contractors will be instructed to disseminate this information as well.

Senate Democratic leaders likely will need to use the cloture process requiring 60 votes to overcome Sen. Bunning's objections. Completing those procedural steps will push final action on the measure into next week.